Hidden Brain - The Lazarus Drug

Episode Date: June 25, 2019

More than 70,000 people died of drug overdoses in 2017 — many of them from heroin and other opioids. One of the most widely-used tools to confront this crisis is a drug called naloxone. It can reverse an opioid overdose within seconds, and has been hailed by first responders and public health researchers. But in 2018, two economists released a study that suggested naloxone might be leading some users to engage in riskier behavior — and causing more deaths than it saves. This week, we talk with researchers, drug users, and families about the mental calculus of opioid use, and why there's still so much we're struggling to understand about addiction. This episode originally aired in October 2018.

This episode contains strong language and mature themes. If you're listening with young kids, I strongly urge you to save this one for later. This is Hidden Brain, I'm Shankar Vedantam. There's an old saying, the best things in life are illegal, immoral, or fattening. There's another way to think about this. Many things that give us pleasure, sex, food, adventure, they contain risks. As a smart species, we've come up with ways to minimize those risks, condoms, seat belts,

drugs to lower cholesterol. But something interesting happens as we do this. As we move the risk-benefit calculation for each activity away from the risk end of the spectrum to the benefit end of the spectrum, we imagine people will become safer. Seat belts, for example, will keep drivers from getting hurt. Now, that would be true if people kept doing things exactly the way they did before. But some people make another calculation. If putting seat belts and cars means you are likely to survive a crash, there's now

a temptation to go faster. An ocean swimer might go out a little further when a life card is nearby. Football players who know their heads are protected by helmets might start to hit a little harder. This phenomenon has a curious name. Economists call it moral hazard. It's a bit of a misnomer because moral hazard has little to do with morality. It's about what happens when you move the risk-benefit calculation to make things safer, and people respond by taking more risks.

So there's a paper, a while back by Sam Peltzmann that kind of lays out the classic case of moral hazard that economists like to point to. This is economist Jennifer Doliak at Texas A&M University. And his idea was that when seatbelts first became required in cars, I think most people would assume when you have seatbelts that's unambiguously a good thing, it's going to save lives. And he saw that and thought, if you have a seatbelt,

maybe you drive a little bit more recklessly. If you have a seatbelt, maybe you drive a little bit more recklessly. Sam Peltzmann found that while drivers were safer because of seatbells, they also drove more recklessly. That would pedestrian's at risk. He argued that the safety benefits of seatbells were cancelled out when you took this into account. Now subsequent studies have challenged this finding, but the seatbelt example illustrates the dilemma posed by moral hazard. Should you make things safer if people are just going to take more risks, or should you allow people to face the consequences of their actions

by doing away with safety measures? This dilemma has political dimensions. Liberals tend to say the more safety measures, the better. Conservatives worry about the negative consequences that interventions might have on personal responsibility. So, are safety measures useful? The answer is, it depends. They can be safety measures that cause so much moral hazard that they make things worse. And they can be other interventions where the benefits far outweigh the risks.

Today we consider this dilemma in the context of a deadly public health crisis. I know I was dead for four minutes by the time the ambulance got there, but they revived me with Narcan. The opioid epidemic. He's playing Russian with men. They knew where the good, the good, the good. A grain of smalls, a piece of salt can kill a human, and it is 10,000 times more potent than morphine.

They would haul us to get that shit, and they figure, okay, well I'll just do a little bit so it won't hurt me. Life, death and trade-offs. This week on Hidden Brain. The Centers for Disease Control and Prevention recently released an astonishing statistic. It estimates that in 2017, about 72,000 people died from drug overdoses. The vast majority of these deaths were caused by overdoses of heroin and other opioids. How do you understand the magnitude of 72,000 debts? I don't know, but I can tell

you one story. It unfolds in a tidy ranch home in Frederick, Maryland. My producer, Jenny Schmitt and I, have made the hour-long drive from Washington, DC. We sit down at the kitchen table and start with introductions. Yes, my name is Hope Troxill. Hello, my name is Pete Troxill. Hoping Pete Troxill live in a neighborhood on a hill just outside of town. I've been here all my life, and my husband and I both. We've been married 46 years, lived in the same area. Hope exudes a comforting warmth. She's the kind of person you want to hug.

Pete is tall and reserved with long white hair and a thick white beard. It's not easy for them to share their story. Hope fidgets. Pete clenches his hands. They begin by telling us about the life they once had. A life that made sense. Their first child was their son Jeremy. He's very easy going. He doesn't get upset. He's very quiet. He'd never said a whole lot when he was young.

Four years later, Alicia arrived. My daughter is more of a strong person. She was determined more so than my son. Alicia was self-possessed, outgoing, a people person. She took risks, like the time when she was just seven, and decided she wanted to compete in a beauty pageant. Hoping Pete drove her to Virginia. Pete wore a tux.

Of course she didn't win, but she was so upset. But we had to tell her that, you know, life is full of disappointments, but you got to go on and you got to move on. And she did, and she got over, she has seven, eight years old, she got over it and... She came in the top 10. She was in the top 10. She didn't come in the first place,

but she was in the top 10 out of the girls. Do you remember what she wore? I remember she had little gown on, but it was, it had the little crown thing and all that. I can't remember what color but it was a little long gown and she's just so cute. That memory of the little daughter in her long gown still makes them both smile.

Hope says as the kids grew older, they stayed close with their parents. Jeremy started working for his dad's trucking business. Hope says she and Alicia will like two peas in a pod. You know, she had to call me every day or I had to be on the phone with her. After Alicia finished high school, Hope convinced her to apply for a job at Ford Detrek, a nearby army installation. Hope worked there too. Alicia started as a cleaning person. Within a couple years, she was walking in the mail room.

She was thriving. She met her soon-to-be husband, and she was pregnant with twins. And my daughter decided, I'm going to go back to college. I said, how can you go to college when you're pregnant? Gonna have two little kids and go to college. So she says, I'm going to do it online. She would put them girls to bed, and then she would go online and do her college, and she got her associates degree

in business. So from there, from that, she moved up again and went to administrative assistant. And my daughter was making good money, really good money. They were proud. Pete says Alicia was the first person in his family to graduate from college. And a decade of hard work at Ford Detrick had paid off. And I mean things were going real good for.

But Alicia also had scoliosis. And as the years went by, it got worse. Of course, she had back problems. And of course, she went to the doctor and they put her own oxycodone. It's a story of our time. Aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, aaaaaah, a, a, a, a, a, a, a, a, She had split from her husband and was in the midst of a divorce. She had moved back in with Pete and Hope and the twins lived there too, part of the time. The oxycodone didn't just help with the back pain. It made Alicia feel better about everything. Then one day, Hope realized her own pain pills, the one she had been prescribed following

a rotator cuff surgery, were running suspiciously low. I would leave my pills set on the counter, and then I could see that maybe one, two pills are being taken, and I'm not taking them. Well then I really started counting. I would actually start writing them down when I would take my pills and my pills should be lasted me longer. And of course I approached my daughter one day and she said, well mom my friend needed. He's having back troubles so my friend needed the ping-pill. I said you don't take't take my pink pills. You come to me first

and ask me. Looking back on it, hope things Alicia was already hooked. They were signs. Like her work, born to work late, saying, um, mom, I need to use this extra time from work. I have all this vacation time. I need to use some of this time from work. I have all this vacation time. I need to use some of this time from work. I would myself would take the girls down the school, drop them off. Notice that more and more she was like, well, I will be late, that can you do this. And I'm like, we are already late for work. Soon skipped hours, tonned into skipped days. I told her one day, I said, you're going to end up losing your job. You got a very good job.

Don't mess it up. But she did after a while, and they left her go from Ford Dietrich. And then things just got worse. She just had a real hard time, what I want to say, functioning. She just couldn't seem to get herself together to be able to even with her girls. Eventually she lost shed custody of the twins. She was able to get her girls if she would do p-test. If she could get a cleaning yard,

she could visit her girls at the Department of Social Services. It was after one of these visits that Hopen Pete believed Alicia finally lost whatever will she had to keep her life together. She drew in with her parents for a supervised visit, Hopen Pete waited in the car. They watched Alicia walk inside, her arms filled with toys. But when she came out of there, I could see her failing because she came out and she was

really crying. She said that they won't even let me hug them. They won't even let me kiss them. And that took my daughter downhill. And she came out there with her toys. The girls didn't want the toys, didn't want to get close to her. They left early. And when she came out that day, that in my heart,

and I believe 100% that that was the turn around point for her to get on a heroin. Once Alicia started using heroin, she lost the remnants of her former life. First went, the last few rights she had left as a mother. The last time was in court, the judge wouldn't even allow our daughter to talk to her girls on the phone.

And I'm like, people in prison get to talk to their kids on the phone. So why did the judge not want to? Sometimes they felt when she did talk to the girls on the phone that either she was nodding out or her speech was slurred. It's hard. I know it's hard for families with this situation, with the drugs. But when you have an addict, you have to help this person. But most people simply turned away from Alicia.

Isolated and addicted, she burned through her savings. She got evicted from her apartment. She also started a new relationship and got pregnant. She was a six months about the time then. And I told her I said, Alicia, you have to get straight now. But she just couldn't. She could not help herself. She had gone to rehab and she was only there five days and she left. She just couldn't do it. But Pieden Hope kept fighting for that child.

They worked with her, pleaded with her. Finally, something shifted in Alicia. She went back into rehab. This time, she made it through the 28-day program covered by Medicaid. When she came out, Pieden hoped to open their doors to her. She was seven months pregnant and very fragile. She was home a week. She's doing great. She shopped for baby clothes. She watched TV at night with her parents. She met a friend for lunch. She and her dad had an honest talk. Pete told her

that he loved her. Alicia said she was sorry for all she'd put them through. One night hope fix Alicia, her favorite meal, corn beef and cabbage. And she was so happy that night. Matter of fact, after we got done dinner, I went back with her. She had these little boy clothes, and her and I was phoned him up and put them away. And she was going to name the little boy Camden, was his name. And her and I were sitting there, like my husband said, he'd come back there. And he told her that he loved her and that everything was going to work out. We all were working together. And we were all working together. sitting there like my husband said he'd come back there and he told her that he loved her and that everything was going to work out. We all were going to work together. Eventually, Hope and Pete went to bed. In the morning, Hope walked to Alicia's room

to bring her the medicine she took to stave off withdrawal symptoms. And I went in and her light was on and I went in, opened the door. And then I saw her. And she was slumped over. I had her deletia. And she did not answer. And I had her for my husband to come running. And he went around where she was at and tried to pull her back. And she was at and tried to pull her back and she was already stiff. So when I called 911, they told us to try to get her on the floor and you give her compressions. And I told the woman, I said, man, she's gone. I knew she's gone. I know she's gone. Camden was also dead.

Alicia Troxill was 34 years old. She left behind her twin daughters, her parents, her brother. Hope and Pete wouldn't allow an autopsy because they didn't want to disturb their unborn grandchild. Hope says blood test showed Alicia had taken a deadly dose of fentanyl. Having just finished rehab, she was especially vulnerable to an overdose because her body had just been detoxed. Alicia's addiction didn't just kill her.

It destroyed the family. Hope and Pete no longer have any contact with their granddaughters. It's something that hopes struggles with. My daughter's viewing that night before. It was so amazing. There was over 150 people there. And I wish my granddaughters could have seen that. They could have seen how loved her.

My daughter was. I had loved their grandparents were. Hope's grief feels like a physical presence. Thinking the air, hard to move through. We all still whole family. I feel like... I have lost my granddaughters, which was... all I had left of my daughter. Thank you. Elisha's story took place 72,000 times in 2017.

To thousands of families, rich and poor, black and white and brown. The scale of this tragedy has generated horror and desperation. Legislators, communities and families have tried everything to stop the deaths. And then a few years ago something appeared that looked and sounded to many people like a miracle. Heroin sets off a chain reaction in the body. Up to a point, it makes users feel euphoric. It takes away stress and pain. But then, if you increase the dose, Herel heroin begins to affect vital functions.

The person's system slows down to a point where they stop breathing and then their brain basically shuts down. Leo Belatsky is a drug policy and public health researcher at Northeastern University. And that process typically takes a substantial period of time with traditional opioids, it can be up to two hours or more. Often, heroin sold on the streets is now laced with fentanyl and carfentanyl. These synthetic opioids are cheaper and stronger. So overdose can occur in a matter of minutes. can occur in a matter of minutes. Now there has long been a way to reverse overdoses. The drug Naloxone. Between 1996 and 2014, the CDC estimates that more than 26,000 overdoses

were reversed by lay people administering Naloxone. Not medics, not doctors, ordinary people. Naloxone has been given the nickname, the Lazarus drug. In the Bible, Jesus restores life to Lazarus. Naloxone doesn't restore the dead, but it comes close. What happens is the person slowly starts to, their breathing starts to return to normal. Their skin starts to turn from its kind of white ash and color, which is what happens during

an overdose, and lips start to return from blue to normal color, and they start breathing again. In late 2015, the Food and Drug Administration approved a new form of naloxone that was much easier to use. It was a nasal spray, and it was a game changer. It was called Narcan. And it came at a critical time. Dets from drug overdoses was skyrocketing. Across the country, massive education campaigns spread the word about the magic drug.

We'll go ahead and start before I start if you could pass your application's forward. On a Thursday morning, I'm in a packed conference room at a Maryland County Health Department. About 30 people sit in three rows. They fall silent as a woman steps to the front. So my name is Jasmine Pierce. I'm the overdose response coordinator

for the Anorondal County Department of Health. You all are here for the Naloxone Narcan Training. This training should be about 30 to 30. It's a free training event for the community that officials hold a couple of times a month. People are here to learn how to administer Narcan to overdose victims. At the end of this training you will receive an Aloxone kit. This kit has two doses of intranasal

and Aloxone. We give two now due to the car fentanyl and fentanyl overdoses that have occurred within our county. Fentanyl and car fentanyl are so powerful that it often takes more than one dose of Narcan to bring a victim back. If you're not familiar with carpentinol that is a tranquilizer used to put large animals down such as elephants. A grain of small as a piece of salt can kill a human and it is 10,000 times more potent than morphine. I always mention that we do provide gloves inside of the kids as well to protect you from any type of contamination because with both of those drugs they can actually seep through your skin with skin-to- skin contact and you can overdose yourself. The CDC says the risk of overdose from such contact is very low.

As Jasmine Pierce continues with the training, the people sitting in the three rows listen intently. Some look shocked, some take notes. There's a high school nurse, a minister, an athletic trainer, a mother, a friend, and lots of heartbreak. After the training session, their stories come tumbling out. My friend Jeff, his knee- niece died of a heroin overdose. Since the front of lines, Godson died and then my son died. He was 22, you know, and he just couldn't, didn't want to stop.

That's what it falls down to. And he had already overdosed like five times the sheet. So he knew it was, he was playing Russian roulette. And then my sister, she was playing Russian roulette. And then my sister, she had overdose in October. She came back, they were able to bring her back with the Narcan. And then last month, she died of an overdose at work on break.

The trainer, Jasmine Pierce, has her own story. It's the one story everyone here wants to be able to tell. The story with a happy ending. I was going to 7-11 one morning before work and I noticed there was a man in his car. He looked like he was sleeping but I started to get a little worried because when I came back out, he looked blue to me. So I knocked on his window, he didn't respond. So thankfully, his door was open. I opened his door, I checked his pulse, and I noticed that he was unconscious, and I

didn't even think I just went ahead and sprayed the narcan, and within 30 seconds he came back. This is the power of the Lazarus drug. Across the country, legislators have rushed to pass laws, increasing access to an Aloxone. Some have urged every family in America to keep the drug closed at hand. Public health officials have assured people that if the administer an Aloxone to someone who is not high on opioids, it won't do anything. With most drugs, you have to worry about misuse and unintended consequences.

That wasn't true of Naloxone. But then, in early 2018, a study came out that suggested Naloxone might indeed have an unintended consequence. One so cruel that had called into question all the good the drug was doing. This finding set off an uproar with many experts rejecting its conclusions. The controversy reflects the mind-boggling complexities of the opioid epidemic and the labyrinth that confronts anyone who finds themselves in this world.

The growing interest and public push to broaden access to Naloxone has been really interesting to me for a while. This again is Texas A&M economics professor Jennifer Dolyak. Jennifer and a colleague economist Anita Mukherjee from the University of Wisconsin knew that Naloxone was effective but there are always trade-offs. That's something we think about all the time as economists. What are the trade-offs involved? The biggest trade-off Jennifer and Anita were interested in was moral hazard. So when it's less risky to consume opioids because Naloxone provides a safety net we might see opioid abuse increase. In other words, could having the safety net of Naloxone provides a safety net, we might see opioid abuse increase. In other words, could having the safety net of Naloxone prompt drug users to take more risks,

like injecting bigger doses of heroin or stronger drugs like fentanyl? Answering such a question scientifically is very, very difficult. The ideal experiment would be to randomly assign Naloxone access to some states but not others. Obviously that's not happening here, but it's helpful to think about that ideal experiment because it gives you a treatment and control group. Since the ideal data were not available, Jennifer and Anita came up with an indirect way to measure where the Naloxone use was affecting opioid use. Some states were passing laws, making it easier to get Naloxone use was affecting opioid use. Some states were passing laws making it easier to get Naloxone. The researchers decided to use these new laws as a proxy for people actually using Naloxone and then compared states that had broadened access with those

that had not. They would then test if there was any difference between these two groups in terms of opioid overdoses and mortality. It was an imperfect experiment, but this was the data they had. Well, even that, you know, it's not random, and so we need to we need to be really careful about making sure we're controlling for everything else that might be going on in those states that we think might have an impact control for pre-existing trends, control for just

pre-existing trends, control for just pre-existing differences across states and levels of opioid use and other policies they might have implemented to address the crisis. With all those controls in place, they thought they may be able to answer the question, what effect was Naloxone having on the heroin epidemic? On net, was it saving lives? It seems reasonable that a drug that saves lives, you know, would, would, on average, have

beneficial effects when you look at mortality rates. I think when we first got into this taper, we really expected to see a big drop in opioid related mortality as a result of these laws. But that is not what they found. In fact, what we found was that on net, we're not seeing any decline in mortality and in some places we actually see an increase in mortality. It was a stunning result. To be fair, Jennifer and Anita found that some states did see a decline in mortality when

they brought in access to an eloxone. But on average, nationwide, mortality did not decline. And in places like the Midwest. We're finding that the Naloxone-access laws caused a 14% increase in opioid-related mortality relative to what would have happened without the law and also a big increase in fentanyl-related mortality, again relative to the counterfactual what would have happened without the law. Jennifer and Anita have a theory about what is going on. Our interpretation is that the risk of death associated with a kind of unit use of heroin or prescription pills has fallen now due to an allocone, but the number of uses and the potency of

uses has gone up so much that it actually, it doesn't just reduce the mortality benefits, but it completely counteracts them in the Midwest in particular. And so what seems to be happening is that opioid use is going up so much as a result of broader access to naloxone that that we're actually seeing an increase in mortality rather than a decrease. Shortly after Jennifer and Anita disseminated a working paper about their

results, the pushback came fast and hard from public health experts. Critics pointed to studies that had reached very different conclusions. At the University of Colorado, Denver, for example, Daniel Rees and his colleagues found that a state's expanded access to Naloxone, there was about a 10% decline in mortality. And at the Federal Substance Abuse and Mental Health Services Administration, Chandler McLellan and his colleagues found an even bigger decline in mortality between the early 2000s and 2014.

Public Health Research, Leo Beletski, says Jennifer Anitas paper was based on flawed assumptions and flawed methodology. It's basically what computer scientists call garbage in garbage out. For one thing Leo says, the paper argued that state laws expanding the lock zone access sign, and increased availability of naloxone in those states. But Leo says, this is wrong. Laws making drugs more available, and a drug actually being available, are two different things. So let's say, you know, the state of New York, does the state of New York have a naloxone law, or doesn't it have the law, is not necessarily a proxy for whether or not an

Aloxone is available on the streets of New York State. Leo has worked on getting such laws passed. You can say with certainty that in many cases the presence of the law was actually a consequence of an Aloxone being available in some areas. So, you know, in New York City, being available in some areas. So, you know, in New York City, Naloxone distribution started back in the late 1990s, for example. The first Naloxone law in New York State was passed in 2013. Now it's worth noting that this critique of Jennifer and Anita's paper also applies in part to the papers we mentioned that found that Naloxone reduced mortality. Leo says Jennifer and Anita's paper,

not only misconstrues what's happening on the ground, but jeopardizes hard-won advances. We have worked for a long time to get these Naloxone laws passed, and in many cases, there was a lot of resistance based on the moral hazard argument in the legislatures to get these naloxon laws passed. It was only the skyrocketing death toll that caused lawmakers to act.

Leo worries that the moral hazard paper will cause legislatures to pull back. Jennifer and Anita stand by their results. It's not lost on us at all that these are lives that we're talking about and that the increase in mortality that we're seeing, you know, these are actual people who have lost their lives due to addiction. And it's depressing just how with so many smart people thinking about this, it feels like we're no closer to solving the problem. The truth is, we don't fully understand how addiction works.

We are still figuring out how to help people quit. We have trouble identifying even what's happening in the course of an epidemic because addiction is stigmatized and people can't talk honestly about their behavior. The data are incredibly messy, regardless of whether you are wearing the hat of an economist like Jennifer Dolyak or a public health scholar like Leo Beletski. At the same time that states were expanding access to Naloxone for example, there was an influx of powerful synthetic opioids into the country. Heroin is increasingly laced with them.

It's possible the recent rise in opioid deaths was driven by the surge in synthetic drugs that have flooded the streets. It isn't just families and researchers and policy makers who are grappling with these life and death issues. Drug users engage in these debates as well, families and researchers and policymakers who are grappling with these life and death issues. Drug users engage in these debates as well, using a mental calculus of their own. People that have mentioned they got that on Bad Batch app now on your phone and people pin where bad batches of dope are. And there's people that download that just to go find the bad batches and do it.

Yeah. Yeah. Yeah. Coming up, the dangerous logic that seeks to balance the risk of death with Euphoria. This is Hidden Brain, I'm Shankar Vedantam. On the day that I attended the Narcan Training at the Anarandal County Department of Health, I met two people who'd come to the on-site clinic for their daily dose of methadone. It's a drug that helps reduce withdrawal symptoms from heroin. One person was using it to stay off heroin, the other to keep from using too much.

We sat down at a picnic bench to chat. We'll only be using their first names. My name is James. Let me get you to tell me your name please. Tiffany. Tiffany is 24 with dark hair and glasses. James is 59, graying and weathered. They should have

little and common, and yet their stories are painfully similar. James started using heroin when he was just 13, a poor kid he says from his Baltimore. Well, when we grew up, my father left us, my mother. He had six children and my father left us with nothing. To help his mom, James says he started hustling on the streets and carrying guns for drug dealers. Then he started carrying that dope and using it. It made him feel better about his life. I didn't feel I didn't want to go to school, I hope school because all my clothes were all wholly this and all of them. My mother had to go to churches, to veterans store, just like a nickel pair of pants,

nickel pair shirt, sense and pair of shoes, you know, and you get tired of that. Tiffany started her drug habit at exactly the same age as James. I started doing, I started doing the percussettes when I was 13. And like James, she says she was pretty unhappy as a kid. Percussette filled the missing parts of her life. When the pills got harder to obtain, she moved on to heroin. And it was just easier to get and around more. It was cheaper. I mean, you really got higher off of it in the less amount.

So. It's a logic that's common to opioid use. Some users would prefer heroin to percuss it because it's cheaper and stronger. And then they might prefer synthetic opioids to heroin for the very same reason. While public health officials warn about drugs like fentanyl, some users go looking for them. If they knew where the good dope was and people were falling out and dying from this shit,

they would run right to get so they would before they sold out. They would haul ass to get that shit and they figure, okay, well I'll just do a little bit so it won't hurt me. Yeah, there's plenty of people to do it. And if there's even people that have mentioned they got that on Bad Batch app now on your phone and people pin where Bad Batches of Doap are. And there's people that download that

just to go find the Bad band batches and do it. Tiffany is referring to a text messaging service that uses data from public health officials. She says that figuring out where the best dope is available at the cheapest price is part of the daily calculation of heroin use. For her part, she spent about $50 a day on her heroin habit. I know, I know $50 a day on her heroin habit. I know, I know $50, that's not really a lot compared to some people on it. I know some people that would be going through a deal or a habit.

Since he was selling the stuff himself, James had easy access to both money and dope. Sometimes, he'd take a little bit for himself before passing the rest on to his customers. There were a lot of moments like this when James and Tiffany rift off each other, building on their shared language of heroin. Another thing they share, they've both overdosed multiple times. The first time for Tiffany was when she was 17. I just didn't fell out. I don't remember. I know I was dead for four minutes by the time the ambulance got there,

but they revived me with Narcan. You've seen it happen so many times. I've overdosed. Nine times. Me too old. Tiffany has overdosed nine times. James 12. They owe their lives to Narcan.

James says he now always keeps a life saving drug. Close at a hand. I got five or six nasal spray narcans up in my room. So if somebody falls out around me, ain't no amelams. I just take the narcan. It's like a nose. You know what I mean? You just put your whole your fingers on it. It looks like a long stem and it goes like that. And it's got another thing point comes down here

that you push in. Like that. So you catch it when they're breathing in And then out then once they're breathing back in that's when they shoot shoot it up their nose Not even 10 15 seconds later. They're arrived. They're back It's some whoever made that Narcanus. Some has some serious Ways of saving people's lives. It's telling you But Narcan also does something unpleasant to users who are high. It brings them crashing down really fast.

When you put that Narcan and you eat everything and any Narcanic, or anything you got in your system, it eats it all out. I mean, it's like scrubbing bubbles. It just goes right through you so fast. And that is not a good feeling. To go from a heroin high to an internal scrub feels awful. That's why many people who are revived with Narcan immediately try to get high again. Just when you went the first time this happened to you do you recall the the you obviously don't recall the Emergency people coming to your house, but you recall what happened right after

I remember going in to the emergency room They sat there and I had to stay there until I was fully coherent Did you have a sense that you actually came close to dying? Yeah, I know As soon as I got out, I did more. I had every single time I overdosed. I did more as soon as I got out of the hospital. It was a revolving door. Heroin Overdoz Narcan. Heroin Overdoz Narcan. I asked Tiffany and James where the Narcan was causing users to take risks that they would not have taken otherwise.

They rejected the idea that Narcan was the reason anyone would choose to get high, but they said the drug might affect how much heroin people use. Where I've noted people say, all right, I've got Narcan, right? They're just going to amp it up more. Tiffany has a friend who is quite explicit about what Narcan does for his drug habit. I know he's mentioned to me quite a few times that if he falls out, we'll come back. They'll come and give him Narcan and bring him back.

So would her friends stop using heroin if he didn't have Narcan? No. Very no way. Tiffany Seese, the moral hazard dilemma of heroin and Narcan. I think that it makes people not be as careful about it, but I also think that there ain't no way that they should take it away because then people are going to be drop and left and right look at everybody that it saves. And among the everybody that it saves is Tiffany.

After multiple overdoses and a blood infection from shooting up that destroyed part of her heart, she finally had enough. I was just, I don't know, I was just done with that kind of life. Like I'm just really sat down and thought about it one day and how I imagined my life to be and who I was going to be. And I just wasn't how I wanted to live no more. And what did you...

When you thought about how you imagined your life was supposed to be and how it had turned out, what went through your head, what did you see in terms of what your life had become? Just everything that addiction does to you, like I wouldn't even mean no more. You do things that aren't you and knowing of how many times I've died, just none of it even made any sense to me. Tiffany now needs methadone to keep withdrawal at bay. She has a heart that beats only because

the damaged portion was replaced with part of a cow's heart. But Tiffany is alive and at 24, she really does have a whole life ahead of her. She is grateful for the chance and would willingly give it to someone else. That's why, even though she isn't using anymore, she always makes sure she has an arcane, close at hand. Yeah, I don't want nothing to happen to somebody and me not be able to save them. I couldn't live with being able to see somebody die and know when it I could have did something. The opioid crisis in America is like a wildfire, racing through towns and cities, consuming individual lives and families and whole communities.

Sometimes amidst all the smoke and fire, you can barely see what's going on. It's likely in the coming years there will be more hard data on the effects of Naloxo. For now, the best we can do is to come to terms with the trade-offs to accept that the interventions we develop to save people might sometimes lead to unintended and unwanted consequences. At those times, it's worth remembering what we are doing right. The people we pull from the flames, charred, damaged, but not yet destroyed. This episode of Hidden Brain was produced by Jenish Mett and Parth Shah.

It was edited by Tara Boyle and Camilla Vargas Restrepo. Atim includes Raina Cohen, Thomas Liu and Laura Quarral. Special thanks this week to Ashley Messenger, Mark Mehmet and Neil Karuth. Aronsang Hero this week is Ellen Jones, the public information director at the Anorando County Department of Health. Ellen invited us to sit in on one of the county's Narcan training sessions. She also encouraged community members to speak with us.

Ellen and her colleagues at the Anorandal County Department of Health are the front-line responders to the opioid epidemic. Even as we focus on helping families and those struggling with addiction, we should all be immensely grateful to folks like Ellen who are dealing with a difficult and heartbreaking job of keeping people alive. For more hidden brain, you can follow us on Facebook and Twitter. If you like this episode, please consider sharing it with a friend and then setting down to chat with your friend about your reactions to it. Good people will disagree when it comes to questions about moral hazard, but we will all be better off if

we can learn from the views of others. I'm Shankar Vedantam and this is NPR.